Patrick Velliky, vice president, government affairs for Envision Physician Services provides an update on the No Suprises Act:

The background: The No Surprises Act was enacted Jan. 1, 2022, with the intent to protect patients that were out-of-network in hospitals. Essentially, patients were held harmless for out-of-network-bills. These bills were sent to arbitration between the payers and the providers. A Qualifying Payment Amount (QPA) was created as a reference point to approximate the “median in-network rate.” Unfortunately, the QPA was calculated by each individual payer. The methodology is controversial, and there has been no oversight, despite a legal requirement for the Department of Health and Human Services (HHS) to perform audits.

This led to four separate lawsuits between the Texas Medical Association and HHS.

• The lawsuits addressed the QPA, the administrative fees that were higher than initially stated and batching laws.
• The fourth lawsuit was the most impactful removing the QPA and identifying specific factors on which to base the rate.

What’s happening now: Currently, the portal is closed while Congress determines how to move forward. The Ways and Means Committee met on Tuesday, Sept. 19 to discuss harm to patients with unnecessary bills and how to improve the current process.

Why it matters: This impacts providers and hospitals as they are not receiving payment until a decision is made. Advocacy from many including the HELP committee led by Bernie Sanders as well as most large staffing companies are helping to highlight the issues.

The goals of advocacy are to:

1. As originally intended by the No Surprises Act, ensure our patients are never held responsible for a bill they shouldn’t have received.
2. Create meaningful incentives for payers to contract at reasonable sustainable rates, and when contracts can’t be negotiated, ensure the mechanisms for determining out-of-network reimbursement are fair and support continued access to care for the communities we serve.

More to come on this topic, and we will ask Patrick back in the future for continued education.